Orders extended for young man with autism and eating disorder while adult wardship application being prepared – 2023vol1#66

See also volume 2 of 2022: https://www.childlawproject.ie/latest-volume/wardship-orders-continued-for-teenage-boy-with-eating-disorder/

The case of a teenager [B] who was the subject of interim wardship orders returned to the High Court with a further application of renewal by the Child and Family Agency (CFA) allowing for his detention in an acute hospital should that be required. When the case had been in one month previously the court had been awaiting a report on the assessment of B’s capacity. The teenage boy, who had a “working diagnosis” of ASD (Autism Spectrum Disorder) had initially been taken into wardship in autumn 2022 for nasal gastric feeding after a continued period of declining food in his residential placement.

The teenage boy, who was soon to reach the age of majority, had a long-standing eating disorder and was currently living in a new residential placement. The report of the social worker provided evidence to the court that whilst B was eating his meals, he was refusing his snacks and declining appointments with speech and language therapy. An adult psychiatric assessment was due to be carried out in order to ascertain if adult wardship was needed. The medical visitor had been sent out on the last court date.

A psychiatric consultant (Psychiatrist One) from the acute hospital where B had been treated gave evidence to the court that the teenager “was a very vulnerable young man with a protracted psycho-social history, early life trauma and was of unsound mind and currently incapable of managing his own affairs”. The consultant told the court that B did not “appear to be able to weigh up medical information, does not follow essential medical advice, [therefore there are] potential lethal consequences of deterioration, with complicating life-threatening situations”.

The medical visitor had already been sent out, therefore the adult wardship jurisdiction had already been invoked, giving the court the jurisdiction to make adult interim orders pending the report of the medical visitor, noted the judge. The existing clinical provisions within the orders allowed for treatment of B through detention in an acute hospital should he require it, if signed off by a psychiatric consultant.

The solicitor for the guardian ad litem (GAL) told the court that the GAL was happy to continue on as GAL when the teenager reached his majority and continued into adult wardship. The judge noted that the order would reflect the fact that from B’s majority he would continue to have the GAL.

The solicitor for the HSE told the court that the consultant psychiatrist (Psychiatrist Two) from B’s new residential placement had instructed them that the young man would “be referred to adult mental health services, whether he meets the criteria is not yet known,” he had been referred to the children’s mental health team but that was not the appropriate referral. The young man also needed access to disability services for future planning, this was a subdivision of the HSE and the in camera rule would need to be lifted in order to allow for the necessary reports to released to that subdivision within the HSE.

Early 2023

The case returned one month later and the court noted the update from the CFA that the assessment by principal clinical psychologist was underway. A diagnosis of ASD would be confirmed. There was also a report from the adult psychiatrist (Psychiatrist Three) who had provided her opinion on the young man’s capacity. The medical visitor’s report was in train and there was also a report from the GAL and a report from the HSE psychiatrist.

The barrister for the CFA made an application to the court to continue the orders from the previous court date, with slight variation, one to reflect that B had attained the age of majority as the interim wardship orders up until that point had been made in the context of child wardship. The current orders in being had been made in the context of an on-going child wardship application, however as the medical visitor had been sent out, the adult wardship jurisdiction of the court had been engaged. The orders to be varied included the appointment of the current GAL under adult wardship, to which the GAL and the HSE were both in agreement.

The solicitor for the HSE sought a direction from the court giving her liberty to provide the disability subdivision with the relevant reports on the young man. Although both services were part of the HSE, the solicitor nonetheless needed a direction from the court allowing one service to release documentation to the other. The judge granted the changes sought to the existing interim wardship orders by the CFA as well as the direction sought by the HSE.

One month later

When the case returned one month later the court was informed by the solicitor for the HSE that the young man had been readmitted to the acute ward for a few weeks since the last court date and was now back in his residential placement. The most recent psychiatric evidence had been from late 2022 in a report from the treating consultant psychiatrist in B’s residential placement.

The barrister for the CFA summarised the background to the case, telling the court that the young man had been a child in care until his majority as his parents had struggled to meet his needs. B had a “very unusual eating disorder of unspecified type and welcomes tube feeding”. In October, wardship proceedings had commenced after a period on an acute psychiatric hospital ward. The young man had been subject to interim orders in minor wardship and was now subject to interim orders in adult wardship. The current type of order was known as “a community treatment order”, which was similar to the UK system where a person can be detained for treatment when required with certain triggers “and that is essentially where this order stands at present, he was discharged from [the acute psychiatric ward in hospital] and then back to [his residential placement], he was in [a placement for children] previously when under 18, the orders were adapted to allow for adult orders in December 2022,” summarised the barrister.

The CFA were seeking those orders to be extended, however he could no longer be treated by Child and Adolescent Mental Health Service (CAMHS), and a referral had been made by CAMHS to the HSE adult mental health services in November 2022. “There has been some HSE disability involvement, but [his new placement] have a significant disability suite of services, when he turns 18 a re-linking in of services [needs to take place].”

The barrister for the CFA told the court that he was now instructed by CFA legal department, as “the division of labour within the CFA has a distinction between minor and adult wardship, he is being transitioned from his childhood circumstances to adult wardship, the CFA isn’t seeking to shirk their role but this is primarily a medical problem.”

When B’s treatment required him to be in either an approved hospital or medical centre, the court had to be notified, noted the barrister for the CFA. The president of the High Court had made the order directing the medical visitor to go out last year, which was the final aspect of the transition of the respondent from legally being a child to being an adult. “This is a case in which the wardship enquiry could take place sooner rather than later”, thereby having a firmer legal basis rather than have complex orders on an interim wardship basis. The most recent psychiatric evidence had been from CAMHS at the end of November 2022 and the court now required adult psychiatric evidence. The hope from the parties was that by the next court date that evidence would be available and they would be in a position to put the grounding application before the court for further orders. “It’s essentially a bespoke detention order, that’s served us well in the past.”

The barrister for the GAL updated the court and said that CAMHS had referred the young man to adult mental health services within the last few weeks. It was not yet known if that referral had been accepted. The solicitor for the HSE had contacted the adult mental health services to inquire whether the referral had been received, as there was some confusion whether the mental health services or the disability services had received the referral from CAMHS.

However the barrister for the GAL highlighted that “a dual approach is required between the adult mental health services and adult disability services, [his residential placement] is excellent at present but that placement is not going to maintain into the future for [B], the GAL raises the point that bespoke expertise may be required.”

The independent social worker supported the interim adult orders being extended for four weeks, which was proportionate, and some form of medical and or psychiatric evidence was required to be available to the court in one month’s time so his rights were not disproportionately affected.

The solicitor for the HSE noted that B did not have a mental health disorder under section 3 of the Mental Health Act 2001 and therefore did not meet the criteria to meet the statutory threshold under section 25 of the Act, which she would have been obliged to bring. The solicitor added that the Children’s Disability Network Team had hoped to assess B before he turned 18 but this had not been possible so the adult services would carry out the assessment to see if the criteria for their disability services were met.

The HSE solicitor explained that the placement the young man was in had been sourced and provided to him by the CFA, now that he was 18, that placement would provide him with psychiatric services. She further explained that under 18s within that placement went to CAMHS as only over 18s were provided with psychiatric services. The young man had a background of trauma that he may have sustained as a young person living with significant family dysfunction. “He worries about his parents a lot, they are both homeless, which is a significant stressor in his life, the HSE is supporting the matter going back for four weeks, judge.”

The barrister for the CFA suggested that the treating clinician in charge of the young man during that hospital stay in the acute psychiatric ward might be in a position to provide the court with a report for the next court date.

The judge told the parties that in terms of lifting the in camera rule, it did not need to be lifted for one part of the HSE to give it to another part of the HSE where the HSE is a party to the proceedings. In giving his ruling on the evidence before him, the judge noted that B had been discharged earlier in the week back to his residential placement.

While in hospital he had been given treatment via a nasal gastric (NG) tube, given his refusal to eat following his admission to hospital. The nurse had said he appeared happy and content on the ward, but continued to refuse meals and to be fed via the NG tube. He had been admitted into hospital after receiving a Christmas visit by his parents in his residential placement. While the visit appeared to go positively, he had subsequently refused to take food. “This is a situation of transition from minorship to adulthood of a young man with complex needs. To date disability services have not been involved, this needs to be assessed as to whether it is the best service to meet his needs.” The principal psychologist within his placement was currently completing an ASD diagnosis and had advised that ASD would be confirmed. That diagnosis and report was expected in the next few weeks.

The young man had asked his independent social worker if she could assist him in getting admitting to hospital to be fed via NG tube and then disengaged from her when she advised that she could not. “He does not have insight into the potentially lethal ramifications into the cycle of refusal of fluid and food. In recent days the position has changed and he is back in the placement. The essential component of him remaining there is for the adult services. The CFA’s opinion remains that his health, development and welfare are at risk should the orders not be extended.”

His GAL had set out his needs in her report, and his expressed views and her recommendations. She had reported that B had been refusing to attend CAMHS. The consultant in his previous residential placement had recommended that he would be weighed at his GP’s, and that his blood pressure and vitals be taken, however he had refused to go there. He had then gone to the acute psychiatric ward in hospital 1. An aftercare worker had been allocated to him and once finished school in June 2023 he would move to the adult part of his current residential placement.

“If disability and adult mental health services are not appropriate then he will need to be referred to the appropriate service in or out of the state,” stated the judge. He added that he was satisfied from the evidence that the court’s wardship jurisdiction remained engaged. “He is currently being well looked after but that is time limited and further evidence on capacity is needed. The appropriate orders to make today involve a continuation of all the current ones,” he said, and allowed the current orders to continue for a four-week period. The judge asked the parties “for as much progress as possible with respect to intervention from the two services and the complex needs of the respondent, the hope is that there will be more clarity. I am very grateful for the care and attention the case is receiving,” he concluded.

Four weeks later

The case returned four weeks later in early March for a Declaration hearing. However the court heard that the young man, who had remained in his residential placement, was essentially under a community treatment order but could be readmitted to the acute ward if required. He had a working diagnosis of complex psychosis involving an uncategorised eating disorder. A capacity assessment had been carried out in late 2022 but a further assessment was being waited on, and the medical visitor was making arrangements to assess the young man. Attempts had also been made by a HSE psychiatric consultant to assess him.

The CFA sought to extend the orders, and while there was no up-to-date medical assessment, there was sufficient medical evidence for a short continuation of orders and it was anticipated that further medical evidence would be available in a short amount of time, he sought to extend the orders to a date in May.

The barrister for the GAL told the court that the GAL had no updated opinion as B had refused her two scheduled visits as well as not accepting or welcoming medical professional visits, and the priority had been to have medical professionals attending, with the psychiatric assessment a particular priority. The GAL had indicated a meeting was taking place this month in respect of care planning going forward if the court was minded to review in May.

The barrister for the HSE agreed the young man’s complete non-engagement had been the pattern all along throughout the last month and his client was happy to agree to continuation of the orders until May.

The solicitor for Hospital 1 sought for her client to be discharged from the proceedings until such time as the young man would be readmitted. A report from the aftercare worker had informed the court of the difficulty in carrying out the assessments and that a further attempt at the capacity assessment would take place. The judge ruled that he had sufficient evidence to enable him to continue the orders made in January and directed that the case be reviewed again in six weeks time.

Six weeks later

When the case returned the barrister for the CFA told the court that the clinical psychologist had “confirmed the diagnosis of ASD and restrictive eating practice”. The barrister advised that he would “anticipate a contested hearing” after B had been served with the inquiry papers as he did not wish to be a Ward of Court. “There is a need for some serious interagency collaboration on this matter, as [B] has been diagnosed as autistic and there is the previous psychiatric report,” saying the young man did not meet the criteria for adult mental health services.

The judge remarked that he had “noticed a major development” in the aftercare worker’s report, that the young man had started to speak. The barrister for the CFA told the court that B had been provided with speech and language therapy and the therapist had advised that B had selective mutism connected with autism. The GAL had visited with the young man and he had communicated verbally with her to some extent. This had commenced after his 18th birthday.

“He wants his file with [his placement] to be closed, wants to live independently and move back to his country of origin. It has been explained to [him] that a judge will have to make the final decision regarding whether he remains a Ward of Court or not, everyone will assist him to use his voice to the court, detailing his own position. He said things are easier now he can be an adult, he wants to get a job, live independently, and does not want to be a Ward of Court, and does not want any state or statutory involvement in his life.” He had asked to send the court that message via his GAL, who was supporting the CFA’s application for the current suite of orders to remain in place.

The barrister for the HSE told the court that the updated report from the HSE psychiatrist was “very clear regarding [B’s] engagement with the mental health services, however we have now obtained a copy of the autism diagnosis, the disability services will review it and there will be an updated response [at the end of] May”. The barrister for the CFA said although the detention orders had not been used, in circumstances where the ASD report was a significant development, there was no difficulty with extending the current orders for the next review.

The President of the High Court delivered his ruling, noting that he was very familiar with B’s case in which there had been the significant development of an ASD diagnosis since the last court date, with a detailed clinical psychological assessment. “Having communicated only in writing and signs, he did commence speaking in the context of his speech and language therapy meeting, towards the end of April.”

The President agreed with the barrister for the CFA that there was a need for “significant interagency cooperation. I don’t want it to happen that the case falls between two stools or even more stools, I think the parties are fully conscious of that, I do hope there won’t be any as I say, falling between the cracks.”

The President noted the views expressed by B, that he wished to exit wardship and live independently. While there ultimately may be an application for discharge of wardship, the GAL was acting in the discharge of her independent duties and was not opposing the application of the CFA to extend the orders “as the orders are appropriate”. The President continued the orders made on the last date, saying their continuation was appropriate”. The case would return again in six weeks time.